Provider Demographics
NPI:1336353275
Name:RUSSELL, REBECCA (NP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660025
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46266-0001
Mailing Address - Country:US
Mailing Address - Phone:317-856-7083
Mailing Address - Fax:317-856-7332
Practice Address - Street 1:10701 ALLIANCE DR
Practice Address - Street 2:
Practice Address - City:CAMBY
Practice Address - State:IN
Practice Address - Zip Code:46113-8836
Practice Address - Country:US
Practice Address - Phone:317-856-7083
Practice Address - Fax:317-856-7332
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001656A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner